Digoxin Use and Lower 30-day All-cause Readmission for Medicare Beneficiaries Hospitalized for Heart Failure

Abstract

BACKGROUND Heart failure is the leading cause for hospital readmission, the reduction of which is a priority under the Affordable Care Act. Digoxin reduces 30-day all-cause hospital admission in chronic systolic heart failure. Whether digoxin is effective in reducing readmission after hospitalization for acute decompensation remains unknown. METHODS Of the 5153 Medicare beneficiaries hospitalized for acute heart failure and not receiving digoxin, 1054 (20%) received new discharge prescriptions for digoxin. Propensity scores for digoxin use, estimated for each of the 5153 patients, were used to assemble a matched cohort of 1842 (921 pairs) patients (mean age, 76 years; 56% women; 25% African American) receiving and not receiving digoxin, who were balanced on 55 baseline characteristics. RESULTS 30-day all-cause readmission occurred in 17% and 22% of matched patients receiving and not receiving digoxin, respectively (hazard ratio {HR} for digoxin, 0.77; 95% confidence interval {CI}, 0.63–0.95). This beneficial association was observed only in those with ejection fraction <45% (HR, 0.63; 95% CI, 0.47–0.83), but not in those with ejection fraction ≥45% (HR, 0.91; 95% CI, 0.60–1.37; p for interaction, 0.145), a difference that persisted throughout first 12-month post-discharge (p for interaction, 0.019). HRs (95% CIs) for 12-month heart failure readmission and all-cause mortality were 0.72 (0.61–0.86) and 0.83 (0.70–0.98), respectively. CONCLUSIONS In Medicare beneficiaries with systolic heart failure, a discharge prescription of digoxin was associated with lower 30-day all-cause hospital readmission, which was maintained at 12 months, and was not at the expense of higher mortality. Future randomized controlled trials are needed to confirm these findings.

Digoxin use and lower risk of 30‐day all‐cause readmission in older patients with heart failure and reduced ejection fraction receiving β‐blockers

“…4 This association appeared stronger in the current analysis, in which all patients with an LVEF <45% were also receiving β-blockers (15% vs 27%; HR: 0.51, 95% CI: 0.31-0.83).…”

“…16,17 Propensity scores for the receipt of digoxin use were estimated for each of the 634 patients using a nonparsimonious multivariable logistic regression model in which the receipt of digoxin was the dependent variable and 30 baseline characteristics displayed in Figure 2 were used as covariates. 4,10,18,19 Using a greedy matching protocol described elsewhere, 20,21 we were able to match 167 (82% of the 204) patients receiving digoxin with 167 patients who were not receiving digoxin but had similar propensity scores (Figure 1). Repeating the above process, from the pre-match cohort of 441 patients with LVEF ≤40%, we assembled a sensitivity cohort of 154 pairs of patients …”

“…31 Efficacy and clinical effectiveness of digoxin in reducing the risk of 30-day all-cause hospital admission and readmission have been well established. 3,4 However, most patients in these studies were not receiving β-blockers, which remains a lingering concern. 32 We have previously demonstrated that in 1842 propensity score-matched patients with HF (30% on β-blockers), a new digoxin prescription was associated with a lower risk of 30-day all-cause readmission (17% vs 22%; HR: 0.77, 95% CI:…”

“…We used the LVEF cutoff of 45% to be consistent with the cutoffs used in the DIG trial and the prior Alabama Heart Failure Project publications. 2,4 Of these, 1046…”

“…3 We have also demonstrated that digoxin use is associated with a lower risk of 30-day all-cause readmission in real-world hospitalized patients with HF. 4 However, in that study, HF patients were not restricted to those with HFrEF, and about two-thirds of the patients were not receiving β-blockers.…”